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TAOG Executive Office Karen O'Briant 141 Idlewild Creek Road Sweetwater, Texas 79556 (325) 235-1959 FAX: (325) 235-4687 TOLL FREE (866) 935-1959 TAOG 
E-mail
© Copyright 2001 Texas Association of Obstetricians & Gynecologists All Rights Reserved Photos by PhotoDisc |
| URGENT INFORMATION REGARDING IMPLEMENTATION OF HB 1983 AND ELECTIVE DELIVERIES <39 WEEKS EFFECTIVE SEPT. 1..... |
September 1 Update to “Claims for Obstetric Deliveries to Require a
Modifier” Information posted August 9, 2011
This is an update to an article titled “Claims for Obstetric Deliveries to Require a
Modifier,” which was published on this website on July 29, 2011.
The article stated that
Texas Medicaid will restrict any cesarean section, labor induction, or delivery following
labor induction to certain criteria for dates of service on or after September 1, 2011.
The implementation date has changed to October 1, 2011 and the list of criteria has
been updated. Following is the complete, corrected article:
Effective for dates of service on or after October 1, 2011, benefit criteria for obstetric delivery services will change for Texas Medicaid. Claims that are submitted for obstetric delivery procedure codes 59409, 59410, 59514, 59515, 59612, 59614, 59620, or 59622 will require one of the following modifiers:
Modifier To Indicate
U1 Medically necessary delivery prior to 39 weeks of gestation
U2 Delivery at 39 weeks of gestation or later
U3 Non-medically necessary delivery prior to 39 weeks of gestation
Note: Claims for deliveries that are submitted without one of the required modifiers will be denied. Effective for dates of service on or after October 1, 2011, Texas Medicaid will restrict any cesarean section, labor induction, or any delivery following labor induction to one of the following additional criteria:
• Gestational age of the fetus should be determined to be at least 39 weeks.
• When the delivery occurs prior to 39 weeks, maternal and/or fetal conditions must dictate medical necessity for the delivery.
Cesarean sections, labor inductions, or any deliveries following labor induction that
occur prior to 39 weeks of gestation and are not considered medically necessary will be
denied. Records will be subject to retrospective review. Payments made for a cesarean section,
labor induction, or any delivery following labor induction that fail to meet these criteria
(as determined by review of medical documentation), will be subject to recoupment.
Recoupment may apply to all services related to the delivery, including additional physician fees and the hospital fees.
For more information, call the TMHP Contact Center at 1-800-925-9126.
NOTE: THE IMPLEMENTATION OF THIS HAS BEEN DELAYED UNTIL OCTOBER 1:
NOTE: This background paper was developed by Dr. Eugene Toy, TAOG President. For questions, please contact ECToy@tmhs.org.
HOUSE BILL 1983 SIGNED BY GOVERNOR
Hospitals and Doctors Must Limit Elective Deliveries Less Than 39 weeks
Governor Perry recently signed into law House Bill 1983, which directs Texas HHSC (Medicaid) to enact cost-cutting measures to reduce non-medically indicated Medicaid deliveries less than 39 weeks, and for hospitals and doctors to work together to develop quality initiatives to reduce these early non-medically indicated deliveries (inductions and ceseareans).
The bill goes into effect on Sept 1, 2011.
Texas Medicaid recently announced it will require providers and hospitals to bill using one of three modifiers (U1/medically necessary delivery prior to 39 weeks of gestation, U2/delivery at 39 weeks of gestation or later or U3/non-medically necessary delivery prior to 39 weeks of gestation). Claims for deliveries that are submitted without one of the required modifiers will be denied.
The program can perform retrospective reviews and ask for reimbursement for those deliveries that are less than 39 weeks without a valid medical indication. There is no time limit stated.
The ramifications for all obstetrical providers and hospitals are vast. In order to avoid reimbursement problems, every hospital should develop its guidelines and protocols for:
Valid medical reasons for delivery less than 39 weeks
Scheduling protocol
Documentation standards
To assist with this tight timeline, the TAOG and District XI ACOG are working together with HHSC to provide templates for hospital guidelines, quality measures, monitoring, scheduling forms, and documentation. Please contact us at info@tx.acog.org if you or your hospital would like training on best practices.
Summary for Hospitals/Physicians: How to Implement the Process-
Step 1: Education- present evidence and rationale
Step 2: Gain consensus- establish your team
Step 3: Get your list of indications, use ACOG indications as template and consider adding other medical reasons
Step 4: Develop your process- how to schedule, how to appeal, how to monitor?
Step 5: Finalize your policy and scheduling form
Step 6: Monitor and be flexible to revise
Some of the background for this initiative may be found in a large research study involving 19 different hospitals and 24, 000 patients published in the New England Journal of Medicine in 2009, investigators found that more than a third of babies were delivered by cesarean without a medical necessity prior to 39 weeks. Infants born at 38 weeks had a 50% greater chance of being so sick as to need neonatal ICU care, and those delivered at 37 weeks were twice as likely to be admitted to the ICU. The gestational age with the lowest risk for neonatal problems was 39 weeks or 40 weeks. These findings have been confirmed by other follow-up studies. Several hospital systems have shown that by reducing early scheduled deliveries, they decreased the number of NICU admissions at all gestational age by 16%. Each neonatal ICU hospital stay costs about $50,000 per infant.
The Joint Commission Accreditation of Healthcare Organizations, American Congress of Obstetricians and Gynecologists, and many insurers have listed early term deliveries without medical indication as a perinatal quality measure. Increasingly, this is an area that hospitals and doctors are being scrutinized.
Examples of valid medical reasons for delivery less than 39 weeks include hypertensive disease, oligohydramnios, IUGR. Examples of not valid medical reasons include patient choice, physician going out of town, history of a fast labor.
Every community is unique, and we advocated very vigorously for the medical decision making, and care of the patient be retained at the local level. Thus, an important part of any hospital guideline is the ability for a practitioner to appeal in a timely manner for a clinical situation that does not appear on the “approved medical indication list,” so that a patient does not suffer intended harm. No list is perfect.
References
Fleischman AR, et al. Obstet Gynecol 2010; 116:136-9.
Tita AN, et al. N Eng J Med 2009; 360: 111-120.
Clark Sl, et al. Neonatal and maternal outcomes associated with elective term delivery, Am J Obstet Gynecol 2009;200:156.
Robinson CJ et al. Timing of elective cesarean delivery at term and neonatal outcome: a cost analysis. Am J Obstet Gynecol 2010;202:632. (Hospital charges $60,000-75,000 per NICU admission, $43,000 cost per this cost analysis)
Joint Commission Perinatal Care Core Measure 1, Elective Delivery. http://manual.jointcommission.org/releases/TJC2011A/MIF0166.html, accessed May 1, 2011.
Kohlkorst: House Bill 1983, signed by Governor 6/17/2011. Texas Legislature Online, http://www.legis.state.tx.us/tlodocs/82R/billtext/pdf/HB01983F.pdf#navpanes=0, accessed June 25, 2011.
Leap Frog Group listing of hospitals on non-medically indicated deliveries http://www.leapfroggroup.org/tooearlydeliveries, accessed January 22, 2011.
[Please read the below from the Texas Health and Human Services Commission for an urgent update on new Medicaid policies for non-medically indicated deliveries less than 39 weeks of gestation.]
Starting September 1, Texas Medicaid is changing its benefit criteria for deliveries, and will deny claims for any induction or cesearean delivery before 39 weeks gestation if not medically necessary and properly documented.
If your practice and/or hospital would like training on the most recent research and how to develop policy guidelines to properly document medically-indicated labor inductions or ceseareans, please contact info@tx.acog.org. Several of our members have recently received training on how to talk to fellow physicians about the research behind this initiative and are available to assist you and your hospital with best practices, so as to avoid problems with Medicaid reimbursement.
As you will recall, HB 1983 allows hospitals to develop policies at the local level.
A sample talk on how to present this to physicians, administrators and nurses and can be found below in the pdf document titled "Sample Talk".
Additional tools will be posted soon. To have any of these documents emailed to you, please contact info@tx.acog.org or taog@hotmail.com
March of Dimes also has some valuable information as well as a downloadable toolkit. Click on the March of Dimes link below for more information.
===============================
EMAIL TO TAOG/District XI ACOG from HHSC:
This announcement is up on the TMHP website today and will go out as a banner message on Monday. As you remember, this was a legislative mandate, as well as a primary initiative of the Healthy Texas Babies project.
Effective for dates of service on or after September 1, 2011, benefit criteria for obstetric delivery services will change for Texas Medicaid. Claims for obstetrical deliveries will require a modifier* for dates of service on or after September 1, 2011. Claims that are submitted for obstetrical delivery procedure codes 59409, 59410, 59514, 59515, 59612, 59614, 59620, or 59622 will require one of the following modifiers:
* U1 Medically necessary delivery prior to 39 weeks of gestation
* U2 Delivery at 39 weeks of gestation or later
* U3 Non-medically necessary delivery prior to 39 weeks of gestation
* Claims for deliveries that are submitted without one of the required modifiers will be denied.
Effective for dates of service on or after September 1, 2011, Texas Medicaid will restrict any caesarean section, labor induction, or any delivery following induction of labor to one of the following additional criteria:
• Gestational age of the fetus should be determined to be at least 39 weeks or fetal lung maturity must be established before delivery.
• When the delivery occurs prior to 39 weeks, maternal andor fetal conditions must dictate medical necessity for the delivery.
Claims for cesarean sections, labor inductions, or any deliveries following labor induction which occur prior to 39 weeks of gestation and are not considered medically necessary, because the medical documentation does not support that decision, will be denied. Records will be subject to retrospective review. Payments made for non-medically-indicated caesarean sections, labor inductions, or any deliveries following labor induction, which fail to meet medical necessity criteria, will be subject to recoupment. Recoupment may apply to all services related to the delivery, including additional physician fees and the hospital fees.
I think that you all were aware that this has been coming and some of your members have been helpful in crafting the language for this policy. Our goal is not, of course, to play “gotcha” with the providers, to recoup payments, or to save money by not paying for these pre-39-week elective deliveries. It is to help guide providers toward these same, sound practice recommendations by ACOG and to reduce morbidity in the neonates from birth trauma and fetal immaturity.
Please let me know if there are any questions or concerns.
Wm Brendle Glomb, M.D., FCCP, FAAP
Associate Medical Director
Texas Medicaid/CHIP Programs
Office of the Medical Director
Texas Health and Human Services Commission (HHSC)
11209 Metric Boulevard, Building H
Austin, Texas 78758
Sample Talk (pdf file of powerpoint presentation)
March of Dimes Toolkit